Surgery?  PT?

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One of the most common orthopedic surgeries is arthroscopic partial meniscectomy (APM), more commonly known as a knee scope. In 2014, it was estimated that 516,800 APMs were performed in the United States, and in 2006, it was estimated that the global cost of this procedure was $44 billion. The meniscus is the cartilaginous pad that is in the middle of every joint in the body. The meniscus prevents bone-on-bone contact in the joint which causes pain, inflammation, and deformation. Tearing of the meniscus may occur as part of the normal degenerative (osteoarthritic) process of the knee and occurs in up to 60 percent of those over age 50, who have not had prior knee pain or injury. The meniscus has no blood supply and so, once torn, it cannot repair itself. Because physical therapy (PT) has positive short-term effects on knee pain and function, the benefit of surgical removal of the torn meniscus as compared to PT has remained unclear. Several smaller studies have been published comparing APM to PT or sham surgery (like a placebo, the scope enters the knee, but no cartilage is removed) and they found no difference in benefit of pain and function between the two groups. A few months ago, a larger study from Amsterdam was published that compared PT to APM for improvement in joint pain and function.

The study looked at over 300 participants with non-obstructive meniscal tears of the knee. Non-obstructive refers to a meniscal tear where the torn part of the meniscus does not enter the knee joint. If a piece of the meniscus enters the joint, it may physically interfere with the function and flexion of the joint. If this occurs, then surgery is required to remove the torn piece.

The participants were randomized into two groups and followed for 24 months. After 24 months, the participants self-reported knee function using a standardized form called the International Knee Documentation Committee Subjective Knee Form. Using the patient-reported knee function information, the study found no difference in knee pain and function between the group randomized to PT versus the group randomized to surgery. However, 29 percent of the PT group did have delayed surgery, demonstrating that not all patients randomized to the PT group were satisfied with their results.

The results of the study do lend credence to the growing opinion that older individuals with degenerative meniscal tears may be able to use PT alone to improve their knee pain and function and avoid, or at least delay, surgery. It is important to remember that these results apply only to those individuals with small meniscal tears. Those with larger tears, bucket-handle tears (the cartilage is flipped over on itself), and obstructing tears most likely will require surgical correction. And those with severely degenerated cartilage where there is bone-on-bone contact will often require joint replacement.

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